The Basics: A beginners guide to acronyms and jargon

It’s been a while since I have published a “Basics” series article.

I am grateful for the interest I have received on this humble blog of my musings in areas from economic development to novel treatment modes and health policy. Some of the feedback I have received has been concerning my occasionally excessive use of jargon and acronyms. My intention with this blog was to provide accessible insights that are both relevant and beneficial to peers within this interest and subject area as well as others who are simply interested in discussion about statistical trends in healthcare or the role of pharma in public health. Some of these terms are explained further in other articles within “the basics” section of this blog – I have linked those articles where relevant. 🙂

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So here’s my growing list of acronyms and jargon for clarification:

AIDS: Acquired Immunodeficiency syndrome

ARVs: Antiretrovial drugs for the treatment of HIV

BMI: Body mass index – (Healthy BMI is generally accepted to be 18.5 – 24.9)

BRICS: Brazil, Russia, India, China, South Africa – large, growing middle-income nations

CDC: Centers for Disease Control and Prevention

CDs: Communicable Diseases

COPD: Chronic Obstructive Pulmonary Disease

DALY: Disability Adjusted Life Year

FDA: United States Food and Drug Administration

GWAS: Genome Wide Association Study

HIV: Human Immunodeficiency Virus

MAb: Monoclonal Antibody

MDG: Millennium Development Goals

NCDs: Non-communicable Diseases

NGO: Non-governmental Organization

NTDs: Neglected Tropical Diseases

OECD: Organisation for Economic Co-operation and Development

PEP: Post-exposure Prophylaxis

SDG: Sustainable Development Goal (based on the United Nations 2030 Agenda for Sustainable Development)

T2DM: Type II Diabetes Mellitus

TB: Tuberculosis

WHO: World Health Organization

 

 

Challenges Facing the South African Pharmaceutical Industry

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As some of you may already know I am a firm and unapologetic believer that the partnership of NGOs, national and international health governance with the pharmaceutical industry, rather than its exclusion, is vital to the effective treatment of disease globally.

From my first experiences at intergovernmental organizations at the age of 16, I came to appreciate the importance of medical research in global health. I have interned at the World Health Organization on two occasions but my experience at Tropical Diseases Research in particular, working with an infectious diseases specialist, designing educational tools for community healthcare workers on the use of a rectal artesunate drug for infants with severe malaria, I realized the need for innovation in the design of drugs and drug delivery systems.

I don’t believe that big pharma is the enemy. I believe the industries of biotechnology and pharma are an invaluable resource; and that the market failures we encounter at scale are primarily a function of the market forces that govern every industry in our world today.

The fact is that the profitability of drugs and vaccines has been a primary driver in the development of the life saving treatments available today. As for those that have fallen through the ‘gaps in the market’, so to speak (see: Antimicrobial resistance; Alzheimer’s, Malaria), I will write on this in future.

  1. HIV: South Africa is doing pretty damn well dealing with the burden of disease

South Africa is a BRICS nation: the growing, middle-income giants of the world. It was the first nation in the world to make Antiretroviral treatment free to all HIV positive individuals at the point of presentation in 2001. Moreover, today, it’s virtually impossible to visit a clinic or hospital in South Africa without being tested for HIV – this means that infections are detected more rapidly than ever.

The result of this is excellent ARV coverage, bearing in mind that this is a lifelong treatment, and HIV positive individuals today live as long as the general population. What this also means is that the nation still has the second highest HIV infection rate globally. Not because management has been poor; but because unlike in many smaller African economies, a sizable proportion of HIV positive patients diagnosed in the mid 2000s survived. This is my measure of success. Moreover, free condoms are infamously everywhere and the South African education syllabus focuses on teaching children about HIV transmission; all this alongside endless television PSAs and government subsidized projects aimed at educating the broader population in this respect.

That said, for Pharma, there has been a decline in new infections. The local pharmaceutical company, Aspen, holds the government ARV tender and the greatest market share in the South African pharmaceutical industry currently.

Opportunity: HIV co-infections present a potential area for growth. The re-emergence of Tuberculosis and certain forms of meningitis present an opportunity for drug development and incremental improvement upon current treatments.

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  1. Litigation: Pharma vs. Government

It’s this battle again. Multinational drug companies are constantly in litigation against the SA government; particularly after the introduction of the 1997 Medicines and Related Substances act.

One thing that has to be understood about South Africa is that, unless you are a South African, you may never fully understand South Africa.

We do overkill like nobody else. But for good reason. Our history of discrimination, dehumanization and suppression of our 90% non-white population means that many of our laws and constitutional requirements are very much shaped towards the complete protection of our population; and rightly so.

That said, our department of health has fought tooth and nail to ensure that drugs are available to the South African people cheaply, ethically and affordably.

Drug companies looking to break into / establish growth in the South African drug market have a lot of regulatory hoops to jump through; some of which may not be ideal for their bottom line – which make smaller, more loosely regulated, faster growing African economies more attractive.

Opportunity: South Africa has a huge growing middle and upper class who are privately insured and willing to pay top dollar for the highest standard of medical treatment. Assuming a firm has taken the potential legal climate into account in calculating their risks and opportunities; South Africa can be a highly profitable market.

  1. An excellent Segway: Generics

The market for generic drugs is massive in South Africa, particularly through the public sector. The highest growing pharmaceutical company in South Africa (by a long shot) is Mylan: a multinational firm that specializes in generics in South Africa (good move).

Moreover, since 2014, new drug compounds have reduced as a contributor to growth in the pharma industry. Price and volume changes are currently the two major areas driving growth in the industry. In my view, in the long term, this is not a sustainable model for growth: prices can only increase so much and South Africans have approximately 2 children per woman which indicates linear population growth and caps the extent to which volume can drive revenue.

Opportunity: In terms of market share, there is still room for growth in the generic drug market.

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  1. Dual burden of disease

I have discussed this topic at length. South Africa is a perfect example of a nation facing the dual burden of communicable and non-communicable diseases. No, malaria has been fully eradicated. But Tuberculosis is a real and verifiable risk and diabetes and COPD are equally so.

Opportunity: See point 2.

  1. Supply chain: Cutting out the middle men?

The drug supply chain from manufacturer to point of dispensing to patient can be rather confusing. Manufacturers typically dispense their drugs through four major routes: independent couriers, wholesalers, distributors or directly to the three major points of dispensing, pharmacies, hospitals and clincs and grocery stores.

I was in Tel Aviv last December and was surprised that I could not purchase any analgesic drug (Tylenol, Panadol, Nurofen, etc.) at any major grocery store. In all of the countries I have lived in, these over the counter drugs were readily available in grocery stores and I had not realized that this is a relatively unique feature globally.

Opportunity: The primary problem with South Africa’s drug supply chain for the pharmaceutical industry and its consumers is that it becomes expensive and these are costs that may (or may not) be transferred to buyers. Streamlining this is an opportunity in itself; and a sector that manages to form valuable partnerships to successfully linearize this process may be able to drive profits.

  1. Reputation

Whilst South Africa is not the recipient of any foreign aid; a number of its geographical neighbors are. In fact, South Africa is the largest contributor of foreign aid to other African states globally.

Nonetheless, pharma doesn’t have the best reputation down south. One reason for this, rarely covered by the foreign media is the leakage of drugs sent to states meeting the criteria, back into the ‘West’.

An example is an OECD scheme to sell drugs to the 49 poorest states. These drugs are sold at either the cost of production plus 10% or at a price reflecting 80% off the average ex-factory price in OECD member states. This is an excellent aid initiative for those states that benefit from this based on World Bank and IMF standards.

Unfortunately, more recent investigations by Belgian customs authorities uncovered large quantities of GlaxoSmithKline products destined for Africa being sold in the European Union. This doesn’t help the already less than favorable view that many already hold of the pharmaceutical industry, not to the exclusion of Southern Africa.

Have a banging Friday

Cheers, peace and love,

Christiana

Coming soon: Rethinking Rabies. A Breakthrough in Management?

Rabies is a vaccine-preventable, zoonotic disease of global concern, resulting in over 55 000 deaths annually. Whilst standard post-exposure treatments are estimated to prevent hundreds of thousands of fatalities, these are not without shortcomings. Recent immunological research into novel treatments has revealed promising results.

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More on this later this week. 

For now, have a stellar Monday!

– Christiana

The Basics: Causes of Death

In the past I have written about how non-communicable i.e. non-infectious diseases make up four of the five global causes of mortality. I have also written about how this is, on the whole, a good thing. This article, although based on strong epidemiological data, is heavy laden in opinion.

The objective of this article is to provide a basic outline of the major causes of death. Everyone dies. And on more than a few occasions, I have heard the comments that all, in their own way, suggest that reducing mortality from specific disease causes is merely an exercise in pushing mortality from one disease cause to another; largely based on funding and location.

I wholly disagree with this sentiment.

It is my opinion that a major objective of improving global health is, beyond widening quality healthcare access for all, increasing the number of healthy life years lived by individuals and populations. In this regard, it is preferable to die of a stroke at older age than the next major influenza outbreak within the next five years, or tuberculosis, or pneumonia, or a lower respiratory tract infection. Moreover, the risk factors for most non-communicable diseases are generally modifiable.

The global reduction in childhood illnesses has been huge, although there is still much work to be done, particularly in Sub-Saharan Africa. Case in point: Diarrheal diseases are no longer amongst the top 5 causes of death. (Can you believe that easily treatable, diarrheal diseases were, until recently, amongst the top 5 causes of death?)

I’m glad we no longer live in that world. And whilst cancers, diabetes and cardiovascular diseases are a major force to be reckoned with within the next 15 years of the SDG era, and likely beyond, based on current trends, we are all projected to live longer. And to me, that says ‘improvement’. Even HIV positive individuals, adherently monitored on Antiretroviral Treatment, are living longer: according to some studies, as long or even up to two years longer than average life expectancy.

Most recent estimates place the top 10 global causes of death as follows:

  1. Ischaemic Heart Disease
  2. Stroke
  3. COPD
  4. Lower Respiratory Tract Infections
  5. Trachea, Bronchus and Lung Cancers
  6. HIV/AIDS
  7. Diarrhoeal Diseases
  8. Diabetes Mellitus
  9. Road Injury
  10. Hypertensive Heart Disease

This is important. It is not important to memorize this list, per se, as they are constantly changing. But it is important; as understanding disease profiles and trends is invaluable to understanding the current, global health landscape.

In future articles I discuss the major problem this poses to health systems, economic development and economic stability for individuals and communities, particularly in low and middle-income settings.

For now, have a stellar Thursday!

The Basics: The Paradox of the Dual Burden – NCDs and CDs

Here’s a fictional allegory:

Thelma lives in a rural area in Tanzania. At age 5, she contracted malaria. Due to broadened availability of health services, Thelma received an artesunate based treatment and, unlike many before her, she survived. In fact, she lived a long, healthy life.

Long enough to reach the age of 55; at which point she developed hypertension and was later diagnosed with Type 2 Diabetes Mellitus.

 

I write this fictional tale here, far removed from the fictional life of Thelma, at my oh-so-trendy standing desk. But fiction or not, it is a scenario that is far too real in many middle and low-income nations. The dual burden of communicable and non-communicable diseases is very real.

Communicable Diseases (CDs): An infectious disease; one transmitted from person to person. e.g. Tuberculosis

Non-Communicable Diseases (NCDs): Diseases that are not transmitted from person to person and generally bare closer relation to lifestyle factors than CDs. e.g. Coronary Heart Diseases

Globally, four of the top 5 causes of death are non-communicable diseases; and the vast majority of the global population lives in low and middle-income nations. But make no mistake, the burden of malaria, HIV and other communicable and tropical diseases remains a force to be reckoned with for many national and regional health systems.

The fact that four of the top 5 global causes of death are all non-communicable illnesses  is a success. It is a success because it is my opinion that the aim of improving global health is increasing the number of healthy life years for the greatest number of people.

Thus, the fact that the majority of the world’s population, including Thelma, now live long enough to develop these arguably lifestyle influenced diseases that occur both later in life and towards the end of an individuals most economically productive years, is a success.

It is vital, however, to understand that none of this is an accident. Cholera, malaria, measles and even polio have not ceased to exist, or occur. It is through consistent, vigilant monitoring, financial investment in the refinement of systems on the part of national governments and associated actors that have kept communicable diseases at bay: they occur, but they do not result in death at the same scale as they did 30 years ago.

Meanwhile, due to globalization and urbanization, amongst the advent of other factors, lifestyles have changed world over. Globally, on average, we are ALL walking less, driving more, consuming a diet higher in saturated fat, sodium and sugar, and living more sedentary lifestyles. These are just some of the many risk factors for NCDs such as Coronary Heart Disease and Type 2 Diabetes (which will no doubt be discussed at length in a future post).

Thus, the emergence of the dual burden. Malaria endemic regions need to remain vigilant in their fight against malaria and despite encouraging numbers, need to maintain funding to maintain progress. Nonetheless, this dual risk and burden mean that investment need also be made in the prevention of NCDs as well as their treatment.

Developing countries today are facing a greater burden than that faced by Europe 100 years ago with regards to Tuberculosis in Sweden and Cholera in England, for example. Today low and middle-income countries are dealing with both old and new; the ailments of the ‘poor’ and the ailments of the ‘rich’, simultaneously. Furthermore, they are dealing with larger populations, different technologies, and regulatory restrictions that the developed world didn’t have to deal with in their fight against widespread NCDs, decades ago.

 

It won’t be easy, but with collaboration, dedication and understanding, it will be done.

 

– Christiana

 

The Basics: HIV, AIDS and related co-infections

I dedicate this to all those who suffered needlessly, died prematurely, were born free but sick; and felt the pain of not only disease but also isolation and stigmatization.

 

I started this blog with the objective of writing about what I know, and love: global health. I want to write about serious issues in a way that is accessible and relevant. I also want to share my opinions.

 

 I’m pissed off. I have noticed a trend of reporting on HIV & AIDS in terms of morbidity and mortality that seems not to draw a distinction between these two related but independent conditions.

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immunodeficiency Syndrome

The attention on HIV and AIDS has simmered down in mainstream media. Indeed, major progress was made in slowing the rate of new infections, AIDS deaths and treating the co-infections with which HIV is associated. But it still irks me every time I HIV and AIDS used interchangeably. I am equally annoyed by the frequent misinterpretation of HIV & AIDS data that leads not only to misunderstanding of disease process but also an underestimation of the progress made by governments, NGOs and major international governing bodies, notably the World Health Organisation.

 

Human Immunodeficiency Virus (HIV) is a virus that can be spread by a number of infection modes. The epithelial linings of the vaginal and anal cavities make them particularly vulnerable to exploitation by the virus. Intravenous infection by the sharing of needles is another way that the HI virus can gain access to the host by the circulatory system. Mother to child transmission also persists as a concern in many regions.

 

HIV can remain latent, showing no symptoms for up to 10 years before progressing to AIDS (in the absence of treatment). Some people progress rapidly from HIV to AIDS. These individuals are called fast progressors. A small percentage of individuals never progress to AIDS, but I will not focus on this in this article, as this is a small minority of patients.

 

HIV currently has no vaccine; and its ability to change its surface proteins and integrate itself within the DNA of the host makes it very hard to develop one.

 

Nonetheless, with antiretroviral treatment (ART) an individual can live a relatively normal, long and healthy life. In fact, some studies have shown that HIV positive patients on antiretroviral treatment tend to live up to two years longer than the average national life expectancy. This may be due to their constant medical monitoring.

 

Once an individual has progressed to AIDS, however, in the absence of any form of ART, their prognosis is poor and death is virtually inevitable.

This brings me to the interpretation of HIV & AIDS data. People die of AIDS. People do not die of HIV. HIV deaths are always associated with comorbidities. The suppression of the immune system caused by HIV makes HIV positive individuals far more susceptible to a range of infections: from cryptococcal meningitis to Tuberculosis and pneumonia.

Some of these are particularly difficult to treat in HIV positive patients.

Moreover, due to the characteristic of latency in HIV, it is common that patients present at clinic and hospital with the confection, unaware of their HIV positive status. This produces new challenges, particularly in the case of Tuberculosis, especially multi-drug resistant tuberculosis. Often the drugs associated with treating these infections, with their long and complicated treatment courses, have a negative interaction with the initiation of ART. There is much debate about when and how to start treatment for HIV and TB in such a way that minimises risk of mortality to patients. Most recent research has shown that the time to start ART after MDR treatment is dependent on how poorly the individuals immune functioning is at the time of presentation; measured by CD4 T-lympocyte count.

This is a topic that will be explored in a later article in detail however I hope that this article has made the distinction between HIV and AIDS clear. I also hope it explains what are sometimes referred to as ‘HIV deaths’ and that even nations with a high population of HIV positive individuals, through the utilization of ART, heavy monitoring and treatment of coinfections in HIV positive individuals, informed by current research, can still achieve a high life expectancy and reasonably high quality of life for its citizens.

 

Cheers, Happy Friday!